Notification of Changes for Business Entity
General Information
Business Entity Name:	EXTEND INSURANCE SERVICES, LLC
Incorporation / Formation Date:
FEIN:	202487260
Ohio License Number:	32852
NPN:	8415824
DBA / Trade Name:
State of Domicile:	UT
County:	SALT LAKE
Business Address
Address 1:	10975 S. STERLING VIEW DRIVE
Address 2:
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Phone:	8014150579
Fax:
Business Web Site Address:
Business Email Address:	LAC@EXTENDHEALTH.COM
Mailing Address
Address 1:	10975 S. STERLING VIEW DRIVE
Address 2:
City:	SOUTH JORDAN
State:	UT
Zip:	84095
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	NO	New DBA/Trade Name:
Amend DBA/Trade Name:	NO	Old DBA/Trade Name:
Add/Delete Producers, Members, Owners, Partners, Officers and/or Directors:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
SANCHEZ, CHRISTINA	BENEFIT ADVISOR	17328397	YES		12/31/15
SANCHEZ, JACOB	BENEFIT ADVISOR	17698734	YES		12/31/15
SANDERS, DAVID	BENEFIT ADVISOR	1250459	YES		12/31/15
SANDLER, ISABEL	BENEFIT ADVISOR	17354209	YES		12/31/15
SANGSTER, CHARI	BENEFIT ADVISOR	17049525	YES		12/31/15
SANK, STEPHEN	BENEFIT ADVISOR	16730592	YES		12/31/15
SAPPINGTON, REBEKAH	BENEFIT ADVISOR	15953989	YES		12/31/15
SATTLER, ROLLIN	BENEFIT ADVISOR	17357310	YES		12/31/15
SCHERBA, RICHARD	BENEFIT ADVISOR	1246419	YES		12/31/15
SCOTT, KIMESHA	BENEFIT ADVISOR	17651539	YES		12/31/15
SCOTT, SHAUNTE	BENEFIT ADVISOR	17697440	YES		12/31/15
SCOTT, ZAKIYYA	BENEFIT ADVISOR	17685877	YES		12/31/15
SCOVILLE, GLORIA	BENEFIT ADVISOR	16700299	YES		12/31/15
SEALOCK, ABBE	BENEFIT ADVISOR	17023708	YES		12/31/15
SEALS, JAZMIN	BENEFIT ADVISOR	16801835	YES		12/31/15

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date

Title Business Entities Only
1. Is any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance? (i.e. banking, auto dealer, mortgage company)
2. Has any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance since the filing of the previous CN-65 or the original application?
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement

Submitted By
Submitted By:	CAMERON LILJENQUIST
Title:	SVP AND CHIEF TECHNOLOGY OFFICER
Phone Number:	8014150579
Email Address:	LAC@EXTENDHEALTH.COM